- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $3,311.31
| Professional | | $891.25 | $1,288.25 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,230.27 / $1,995.26
| Professional | | $912.01 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,548.82 / $2,454.71
| Professional | | $151.36 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,570.40
| Professional | | $1,023.29 | $1,513.56 | $2,570.40 |